AUTHENTIC
ENGAGEMENT
AND THE REDUCTION OF PATIENT AGGRESSION
OBJECTIVES
Upon completion of this in-service, participants will be
able to :
• Examine consequences of being exposed to client
aggression
• Describe research addressing aggression
• Identify authentic engagement components to
improve inpatient psychiatric nursing practice and
prevent escalation in client aggression
• Demonstrate the implementation of authentic
engagement during a role play session
INTRODUCTION
AUTHENTIC ENGAGEMENT: A CORE
CONCEPT IN REDUCING SECLUSION
AND RESTRAINT
• Reducing seclusion rates is challenging and
typically requires the implementation of multiple
interventions (Gaskin, Elsom, & Happell, 2007).
• Finfgeld-Connet’s Nursing Theory of Authentic
Engagement provides tools to help prevent client
aggressive behavior.
LEVELS OF AGGRESSIVE BEHAVIOR
• Agitation- nervous excitement, excessive motor or
verbal activity, irritability and uncooperativeness
(Zeller & Rhoades 2010)
• Aggression- a readiness to attack or confront
• Assault
• Simple assault- has ability and shows intent to injure,
however threat would not require medical attention
• Assault and battery- has the ability and shows intent to
injure, and makes physical contact
• Aggravated assault- Is separated from simple assault
because there is an intent to seriously injury. This injury would
require immediate medical attention.
ASSESSMENT OF AGITATION
• Experienced psychiatrist and psychiatric nurses have been
shown to be able to accurately predict violent behavior.
• “One study found that psychiatrist and psychiatric nurses
correctly predicted violent behavior in 82% and 84%
respectively, of newly admitted psychiatric patients”
(Zeller &Rhoades, 2010 p.420)
FACTORS CONTRIBUTING TO PATIENT
AGGRESSION
Internal
• These include individual patient variables such as age, gender
and serious mental illness diagnosis
• Suggested that young males are most prone to violence
External
• Limited space or privacy, overcrowding, hospital shifts and
raised temperatures
• Staff experience, gender and training also have an impact on
patient escalation
• Handover periods and meal times are problematic
Situational
• A combination of internal and external factors.
(Duxbury, 2002)
CONSEQUENCES OF BEING EXPOSED TO
INPATIENT UNIT AGGRESSION
Staff
• Mental health second most
violently victimized group
(Finfgeld-Connett, 2009)
• 61% of nurses working in
psychiatric settings had been
physically assaulted in their
career
(Zuzelo, Curran & Zeserman, 2012).
• Interdependent relationship
with staff burnout
• Physical injuries
• Emotional damage
CONSEQUENCES OF BEING EXPOSED TO
INPATIENT UNIT AGGRESSION
Patients
• Can result in seclusion or
restraint
• Psychological injuries
resulting from activation
of traumatic memories of
pervious incidence of
abuse and violence
(Bonner et al. 2002)
• Physical injuries
• Patient aggression may
delay discharge or make
placement more difficult
WHY IT IS SO IMPORTANT TO REDUCE
AGGRESSION
• Foster et al. (2007) write, “…daily exposure to
swearing, threats and verbal abuse can cause
lasting emotional damage to nursing staff” (Foster
et al., 2007 p. 146).
• This emphasizes the need for interventions that take
place during the agitation phase of an incident
rather than waiting for the verbal or physical
aggression.
LITERATURE REVIEW OF
RESEARCH EVIDENCE
THERAPEUTIC INTERVENTIONS FOR
AGGRESSION
• Staff and patients
had different beliefs
about the causes of
aggression
• Patients-poor
communication the
number one precursor
to aggression
• Staff- patient illness the
number one cause
(Duxbury &Wittington, 2002)
THERAPEUTIC INTERVENTIONS FOR
AGGRESSION (CONTINUED)
• Effective de escalators are “open, honest,
supportive, self-aware, coherent, non-judgmental
and confident without appearing arrogant” (Price &
Baker, 2012 p.312).
• Successful management of aggression involves
creativity and flexibility.
• Tailored to specific patient needs (Price & Baker, 2012).
• Embodied moment (Carlsson, Dahlberg & Drew, 2000).
THERAPEUTIC INTERVENTIONS FOR
AGGRESSION (CONTINUED)
• Early intervention is key in success.
• Acting proportionately to the risk the patient is
presenting (Bowers, McCullough &Timmons, 2003).
• Soft, calm and gentle tone of voice and appearing
calm (Ryan & Bowers, 2006)
• Balance support and control (Delaney and Johnson, 2006)
• “Stressed the importance of offering “face saving’
alternative to violence” (Gertz, 1980)
EFFECTIVENESS OF TRAINING
PROGRAMS
• There is a lack of research that identifies evidencedbased components of aggression management
programs (AMP).
• One review suggested that there is lack of
consistency between the content covered
between AMPs and that there is a lack of evidence
surrounding the ability of these programs to change
staff behavior (Farrell & Cubit, 2005).
A COMPARISON OF MOAB AND PROACT
Moab
Emphasizes planning and teamwork
Pro act
Yes
Teaches prevention
yes
yes
Includes de-escalation techniques
yes
yes
Addresses triggers and alternatives
yes
yes
Employees critical thinking and problem-solving
techniques
yes
yes
Keeps patient at the center of care, attempts to meet
the underlying patient need
Focuses on problem behavior
yes
yes
yes
Emphasizes patient rights
yes
Teaches self-awareness
yes
Includes documentation component
yes
Teaches techniques to defend and subdue
yes
(Osborn, 2013)
AUTHENTIC ENGAGEMENT:
METHODOLOGICAL CONSIDERATIONS
• Meta-synthesis of 15 qualitative research articles for
nursing management of aggression
• Data included direct quotes, coding schemes and
discussion
• Authentic engagement was the core category
around which the data was organized.
• From this work, the author proposed a model of
therapeutic responses to patient agitation.
(Finfgeld-Connet, 2009)
(Finfgeld-Connet, 2009)
MODEL OF THERAPEUTIC AND NON
THERAPEUTIC RESPONSES TO PATIENT
AGGRESSION
(Finfgeld-Connet, 2009)
MODEL FOR THERAPEUTIC
RESPONSES
ESCALATING OF PATIENT NEEDS
• Finfgeld-Connett asserts that aggressive episodes
are preceded by an escalating series of stages
where patient needs go unmet.
• “Aggression was defined as any verbal or non
verbal behavior that is threatening or actually
results in harm to nursing personnel” (Finfgeld-Connet, 2009
p. 530)
• As agitation increases the patient’s cognition
decreases. This highlights the importance of acting
early.
RESPONSES STYLES
Therapeutic
• Intuitive
• Patient's needs are
immediately understood
• Adaptable interventions
match these needs
• Emergent
• Acting in a carefully
measured way
• Rely on education and
training
Non-Therapeutic
• Inflexible
• The use of rigid rules and
physical methods to
control patient behavior.
• Excessively task oriented
• Disengaged
• Nurse managers are
authoritarian, but distant
• Administrative
abandonment
(Finfgeld-Connet, 2009)
AUTHENTIC ENGAGEMENT
• Finfgeld-Connet found that authentic engagement
was a core component of both the intuitive and
emergent therapeutic response styles.
• Becoming and staying genuinely connected to the
patient
• Keep communication lines open, while being
steady and dependable
• This person to person bond helps patients to regain
control.
(Finfgeld-Connet, 2009)
SITUATIONAL CONTEXT
• Aggression is a way to express feelings
• Can serve as a catalyst to get things done, if the underlying
need can be identified
• Therapeutic interventions may fall outside the
standardized rules and guidelines.
• Appreciation for the patient “strange world”
• Awareness of general
environment milieu, such as noise
levels and other patients on the
floor
Click here for
more
information
(Finfgeld-Connet, 2009)
RECIPROCITY
• Approach a situation with recognition and
reciprocity rather than a sense of self-importance or
superiority.
• Help patients maintain a sense of dignity by
bargaining and negotiation.
• Show respect and fair mindedness.
• Letting patient know what you are doing ahead of time.
(Finfgeld-Connet, 2009)
LIMIT SETTING
• The importance of a well organized and
predictable milieu.
• Group schedule, rounds, favors
• Clearly communicate that inner control is expected
from the patient.
• If the patient is unable to do this then external
control will be necessary.
• Matching the response to the level of
dangerousness.
(Finfgeld-Connet, 2009)
TEAM WORK
• Effective multiple disciplinary teams plan ahead
and talk openly about how to manage patients
who have an increased potential for violence.
• The team approach is also important for direct care
staff.
• Staff debriefings
(Finfgeld-Connet, 2009)
NON THERAPEUTIC RESPONSE
• Nurses feel demoralized and traumatized, which
may become a self-perpetuating cycle
• Patients feel mistreated and ignored.
• Erodes patient trust that the hospital is a place where they
can get help in a time of crisis (Duxbury, 2002)
• Poor management of aggression and the Impact
on the unit…
•
•
•
•
Burnout
Absenteeism
Reassignment
Resignation.
IMPLEMENTATION COMPONENTS OF
AUTHENTIC ENGAGEMENT
• Situational context
• Providing a low stimulation room
• Providing pre packaged food to a paranoid patient
• Reciprocity
• Negotiating with patients who may want a restricted item,
instead of saying no try to look for a way to balancing safety
and patient preference
• Limit setting
• Clearly communicate that inner control is expected in the
patient handbook
• There are times when negotiation is not appropriate
• Teamwork
• Charge nurses attending 1700 Resident report
• Finding the balance between reciprocity and limit setting is a
team effort.
AUTHENTIC ENGAGEMENT IN
PRACTICE
• Aligning with the
patient who
wanted to be
discharged.
• Negotiating with a
patient refusing to
have a photo taken
POTENTIAL BARRIERS
• The belief that seclusion is the only way to keep the
unit safe.
• Disempowerment of nursing staff.
• Difficult to describe the balance between limit
setting and reciprocity in words.
• Stressors in a nurse’s personal life
• Incomprehensible underlying patient needs.
CONCLUSION
• Authentic Engagement is one interventional model
that can help nursing staff to intervene before a
patient become aggressive.
• There are many causes of aggression that are
outside of our control. For example, the long wait
times for court order medication. However,
authentic engagement techniques provides a
pathway to more effective care and a safer work
environment.
REFERENCES
• Bonner, G., Lowe, T., Rawcliffe, D., & Wellman, N. (2002). Trauma for all: a pilot study
of the subjective experience of physical restraint for mental health inpatients and
staff in the UK. Journal of Psychiatric and Mental Health Nursing, 9(4), 465–473.
• Bowers, L., Nijman, H., Simpson, A., & Jones, J. (2010). The relationship between
leadership, teamworking, structure, burnout and attitude to patients on acute
psychiatric wards. Social Psychiatry and Psychiatric Epidemiology, 46(2), 143–148.
doi:10.1007/s00127-010-0180-8
• Carlsson, G., Dahlberg, K., & Drew, N. (2000). Encountering violence and aggression
in mental health nursing: A phenomenological study of tacit caring knowledge.
Issues in Mental Health Nursing, 21(5), 533–545.
• Delaney, K. R. (2009). Reducing Reactive Aggression by Lowering Coping Demands
and Boosting Regulation: Five Key Staff Behaviors. Journal of Child and Adolescent
Psychiatric Nursing, 22(4), 211–219. doi:10.1111/j.1744-6171.2009.00201.x
• Duxbury, J. (2002). An evaluation of staff and patient views of and strategies
employed to manage inpatient aggression and violence on one mental health
unit: a pluralistic design. Journal of Psychiatric and Mental Health Nursing, 9(3), 325–
337.
• Duxbury, J., & Whittington, R. (2005). Causes and management of patient
aggression and violence: staff and patient perspectives. Journal of Advanced
Nursing, 50(5), 469–478.
REFERENCES
• Farrell, G., & Cubit, K. (2005). Nurses under threat: a comparison of content of 28
aggression management programs. International journal of mental health nursing,
14(1), 44–53.
• Finfgeld-Connett, D. (2009). Model of Therapeutic and Non-Therapeutic Responses
to Patient Aggression. Issues in Mental Health Nursing, 30(9), 530–537.
doi:10.1080/01612840902722120
• Gaskin, C. J., Elsom, S. J., & Happell, B. (2007). Interventions for reducing the use of
seclusion in psychiatric facilities: Review of the literature. The British Journal of
Psychiatry, 191(4), 298–303. doi:10.1192/bjp.bp.106.034538
• Gertz, B. (1980). Training for prevention of assaultive behavior in a psychiatric
hospital. Hospital and Community Psychiatry, 31, 628-630
• May, B. (2010). Orlando’s nursing process theory in nursing practice. In M. R.
Alligood & A. M. Torney (Eds.), Nursing theory: utlization & application (4th ed., pp.
337–357). Maryland Heights, MI: Mosby Elsevier.
• Orlando, I. J. (1990). The dynamic nurse-patient relationship. New York, New York:
National League for Nursing.
• Price, O., & Baker, J. (2012). Key components of de-escalation techniques: A
thematic synthesis. International Journal of Mental Health Nursing, 21(4), 310–319.
doi:10.1111/j.1447-0349.2011.00793.x
REFERENCES
• SAMHSA Seclusion and Restraint - Statement of the Problem and
SAMHSA’s Response. (n.d.). Retrieved September 8, 2012, from
http://www.samhsa.gov/seclusion/sr_handout.aspx
• Scanlan, J. N. (2009). Interventions To Reduce the Use of Seclusion and
Restraint in Inpatient Psychiatric Settings: What We Know So Far a Review
of the Literature. International Journal of Social Psychiatry, 56(4), 412–423.
doi:10.1177/0020764009106630
• Sullivan, A. M., Bezmen, J., Barron, C. T., Rivera, J., Curley-Casey, L., &
Marino, D. (2005). Reducing Restraints: Alternatives to Restraints on an
Inpatient Psychiatric Service/Utilizing Safe and Effective Methods to
Evaluate and Treat the Violent Patient. Psychiatric Quarterly, 76(1), 51–65.
doi:10.1007/s11089-005-5581-3
• Zeller, S. L., & Rhoades, R. W. (2010). Systematic reviews of assessment
measures and pharmacologic treatments for agitation. Clinical
Therapeutics, 32(3), 403–425. doi:10.1016/j.clinthera.2010.03.006
• Zuzelo, P. R., Curran, S. S., & Zeserman, M. A. (2012). Registered Nurses’
and Behavior Health Associates’ Responses to Violent Inpatient
Interactions on Behavioral Health Units. Journal of the American
Psychiatric Nurses Association, 18(2), 112-126.
PICTURE REFERENCES
Slide 4
http://www.southernpoliceequipment.com/shop/default.asp?h=c&c=13&id=1684
Slide 6
www.telegraph.co.uk/news/worldnews/northamerica/usa/8296557/Remains-ofthousands-of-patients-found-at-One-Flew-Over-the-Cuckoos-Nest-institution.html
Slide 9
www.creativitypost.com/psychology/must_one_risk_madness_to_achieve_genius
Slide 12
www.hrea.org/erc/Library/primary/Opening_the_Door/workshop16.html
Slide 15
www.proact.com; http://www.moabtraining.com/main.php
Slide 25
heartlandwriting.wordpress.com
Slide 27
www.fineartamerica.com/featured/red-ants-teamwork-peerasith-chaisanit.html
Slide 30
www.proprofs.com
Slide 31
http://www.finest.se/userBlog/?uid=39305&beid=2486574
QUESTIONS?
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questions:
mailto:firelight33@gmail.com?subject=AE
presentation
ROLE PLAY PRACTICE SESSION:
30 MINUTES
• A patient demanding discharge
• A patient refusing a search after coming back from
a pass
• Denial of a request for pain medication
• A patient who is disorganized and psychotic
• An intrusive patient
Role Play Instructions